The Woman's College of The University of North Carolina

LIBRARY

COLLEGE COLLECTION CQ no. 654

Gift of Nancy Taylor Coghill

COGHILL, NANCY TAYLOR. Responses of Nurses, Pediatricians and Hospital Administrators in North Carolina to a Play Activity Center Questionnaire. (1969) Directed by: Dr. Helen Canaday. pp. 77

The purpose of this study was to survey by means of a questionnaire

the pediatric staff members in the hospitals in North Carolina. Respondents

were hospital administrators, staff pediatricians and pediatric nurses. The

questionnaire was designed to investigate the acceptance of pediatric play

activity centers and the understanding of the play activity center director's

role. The null hypotheses were:

1. There is no difference in the acceptance of play activity

centers among pediatric nurses, pediatricians and hospital

adminis trators.

2. There is no difference in the perceived need for trained

personnel for play activity centers among nurses, pedia-

tricians and hospital administrators.

A pre-survey to locate the target population was made of the 70

North Carolina general hospitals with a bed complement of 100 or more.

Thirty-two of these hospitals claimed to have a pediatric unit and

thus comprised the target population.

Questionnaires were distributed to the hospital administrator,

a pediatrician and a pediatric nurse in each of the hospitals in the

target population. There was a total of 96 questionnaires distributed.

Sixty-three questionnaires or 65.6% were returned to the investigator.

Reliability of the questionnaire was measured by comparison of

six factual questions within the individual hospital respondent sets.

Since the survey was made of a total population rather than a

random sample, percentage analysis was the technique used to analyze

the data. The results of the data were discussed on the descriptive level.

There was complete agreement among the respondents on the value of existing

play activity centers. There was less agreement on play activity center

value among the respondent classes from hospitals not having a play

activity center. The most often selected primary value of a play activity

center by all classes was "Reduction of Emotional Stress." There was

also agreement on "Entertainment" as the second most often selected play

activity center value. "Child Development" was ranked as the most pre-

ferred and "College Degree - Any Major" was ranked as least preferred

training for the play activity director by all three classes of respon-

dents. "Nursery School" was ranked as most preferred experience by the

three respondent classes. The aspect most often selected by all three

respondent classes as important in the play activity director's role

was "Schedule activities for the play activity center." Trends toward

agreement among the classes appeared with relation to both hypotheses.

RESPONSES OF NURSES, PEDIATRICIANS

AND HOSPITAL ADMINISTRATORS IN

NORTH CAROLINA TO A PLAY

ACTIVITY CENTER

QUESTIONNAIRE

by

Nancy Taylor Coghill

A Thesis Submitted to the Faculty of the Graduate School at

The University of North Carolina at Greensboro in Partial Fulfillment

of the Requirements for the Degree Master of Science in Home Economics

Greensboro March, 1969

Approved by

Thesis "Adviser ~

APPROVAL SHEET

This thesis has been approved by the following committee

of the Faculty of the Graduate School at The University of North

Carolina at Greensboro.

Thesis _w _ Adviser ..//c-£<

Oral Examination Committee Members

^-fc-c^ L^CL-vt-cu&--0-< is'

'JSMC C-Yi ~7?l L<^gc

h Date of Examination

ii

ACKNOWLEDGMENTS

As author I wish to extend sincere appreciation to the fol-

lowing people:

Dr. Helen Canaday, director of the thesis, for whose assistance

the author is most grateful.

Dr. Faye Grant, Dr. Rebecca Smith, Dr. Eugene McDowell and Dr. Carl

Cochrane whose suggestions have been very helpful.

The hospital administrators, staff pediatricians and pediatric

nurses who took part in the survey.

My parents, Mr. and Mrs. E. Bruce Taylor, whose encouragement

throughout my academic career has been sincerely appreciated.

My husband, Phil, whose many hours of technical assistance with

data analysis and printing of the manuscript are duly acknowledged.

Without his interest and encouragement this study would not have been

possible.

N.T.C.

iii

TABLE OF CONTENTS Page

Acknowledgments ili

List of Tables vi

I. THE PROBLEM 1 Purpose of the Study 2 Hypotheses 3 Definitions 3 Basic Assumptions 4 Data Secured 4 Limitations of the Study 5 Organization of the Remainder of the Thesis. 5

II. REVIEW OF LITERATURE 6

III. PROCEDURES 16 Development of the Questionnaire 16 Determination of the General Hospital

Population 17 Determination of the Target Population ... 17 Distribution of the Questionnaire 18

IV. ANALYSIS OF THE DATA 19 Data Collection 19 Reliability of the Questionnaire 20 Analysis of the Data 22 Hypothesis I 22 Hypothesis II 28

V. SUMMARY, CONCLUSIONS AND RECOMMENDATIONS .... 37 Conclusions 39 Recommendations for Further Study 41

BIBLIOGRAPHY *3

APPENDIX A General Hospitals in North Carolina With a Bed Complement of 100 or Greater and Claiming To Have a Pediatric Unit 45

APPENDIX B Letter and Postal Card to the Administrators of All North Carolina General Hospitals With a Bed Complement of 100 or More 48

34044V iv

Page APPENDIX C Letter to the Administrators of

All Hospitals in the Target Population 51

APPENDIX D Questionnaire 53

APPENDIX E Results of Rank Order of Preferred Training of Play Activity Directors 60

APPENDIX F Results of Percentage Analysis of Preferred Training of Play Activity Directors 63

APPENDIX G Results of Rank Order of Preferred Experience of Play Activity Directors 67

APPENDIX H Results of Percentage Analysis of Preferred Experience of Play Activity Directors 70

APPENDIX I Results of Percentage Analysis of The Most Important Aspects of the Play Activity Director's Role 74

APPENDIX J Results of Percentage Analysis of Those Responsibilities Not a Part of the Play Activity Director's Role 76

LIST OF TABLES

Table

1

10

11

Percentage Distribution of Returned Questionnaires

Analysis of Responses to the Question: "In your opinion, is this play activity center of value to the pediatric unit in your hospital?"

Analysis of the Responses to the Question of Requirements For a Play Activity Director in Existing Play Activity Centers

Analysis of the Responses to the Question: "In your opinion, would a play activity center be of value to the pediatric unit of your hospital?"

Analysis of the Responses to the Question: "Would you consider converting this space into a playroom?"

Analysis of the Responses to the Question of Requirements For a Play Activity Director to Fit Pediatric Unit Needs

Analysis of the Responses to the Question: "What, in your opinion, is the most important value of a play activity center?"

Rank of Preferred Training For Play Activity Directors

Percentage Analysis of the Most Preferred Play Activity Director Training Type - Child Development

Percentage Analysis of the Least Preferred Play Activity Director Training Type - College Degree - Any Major

Rank of Preferred Experience of Play Activity Center Directors

Page

20

23

24

25

25

26

27

29

30

31

32

Table

12

13

14

15

Percentage Analysis of the Most Often Preferred Play Activity Director Experience

The Three Most Often Selected Role Aspects By Administrators

The Three Most Often Selected Role Aspects By Pediatricians

The Three Most Often Selected Role Aspects By Nurses

Page

33

34

35

35

vii

CHAPTER I

THE PROBLEM

From the available literature and professional contacts it appears

that there is an increasing awareness of the non-medical needs of hospi-

talized children. As a result of the realization of these special needs,

play activity centers are being introduced to some large hospital pediatric

units to help meet the needs of the patients. Further considerations of

the play activity program beyond special stress needs are those needs

consistent with the growth of all children. As Cohart (1956-57) explained,

"...we must not focus attention on the disease to such an extent that

we forget about the whole child Qp. 203."

The use of play has been reported in many journal articles as

having value for both the well and the ill child. Three of these

specific values are: self expression, emotional discharge and handling

fears. Senn (1945) combines the emotional aspects of convalescence

with a discussion of play in a comprehensive manner. Davidson (1948),

and Richards and Wolff (1940) provide further support for the value

of play and the hospitalized child. Thus, an application of these

values by inclusion of play into the hospital program for short-term

convalescent children appears to lessen the child's adverse reaction to

the hospital experience as well as to assist in the continuation of

his normal developmental pattern.

Research and pilot programs are being conducted which suggest

further an increasing awareness of the value of play to the hospitalized

child. Faust, Jackson, Cermak, Burtt, and Winkley (1952) studied the

effects of adequate emotional preparation of the young child on his reac-

tion to surgery. Prugh, Staub, Sands, Kirschbaum, and Lenihan (1953)

reported their short-term longitudinal study of conditions of communica-

tion, staff support, parental and play programs as they related to

emotional reactions of hospitalized children. Tisza and Angoff (1957)

reported an experimental play program at Boston Floating Hospital and

Cassell (1965) experimented with techniques of puppetry as a preparation

for cardiac catheterization at Children's Memorial Hospital, Chicago.

Purpose of the Study

Within the pediatric unit an organized play center directed by

personnel trained in child development or closely related disciplines

would appear to allow the child maximum benefit from these play expe-

riences. Therefore, a survey of the present provisions for such pro-

grams in North Carolina hospitals as well as the opinions concerning

these programs from hospital administrators, nurses and staff pedia-

tricians could determine if there exists a need for additional play

centers and trained child development specialists.

The purpose of this study was to survey the general hospitals

in North Carolina which have pediatric units. A questionnaire was used

to provide information about present play facilities, proposed play

activity centers, and staff qualifications and training. Comparisons

of the responses of hospital administrators, pediatricians and pediatric

nurses were made to determine the degree of acceptance of play activity

centers among members of the pediatric staff. The understanding of the

purposes and personal opinions toward a play activity center and its

director were also surveyed in order to gain a better understanding of

the current acceptance and potential establishment of play activity cen-

ters in North Carolina hospitals.

Hypotheses

(1) There will be no difference in the acceptance of play

activity centers among pediatric nurses, pediatricians

and hospital administrators.

(2) There will be no difference in the perceived need for

trained personnel for play activity centers among

nurses, pediatricians and hospital administrators.

Definitions

(1) play Activity; Play activity is the extra-medical care

provided for the child in an acute short or long term

hospital situation. It includes group activity for

children, toddler through mid-teenage, within a playroom

setting as well as individual activity for patients

confined to their rooms. All activity is supplemental

to the care provided by the medical staff and is direc-

ted toward the needs of the developing child as an indi-

vidual within the hospital setting.

(2) Play Activity Center: A play activity center is a separate

area on the pediatric floor which is staffed and equipped

to provide patients with an opportunity to engage in super-

vised play.

(3) Child Development Specialist: A child development specialist

is a person trained in the child development curriculum at

either the Bachelor's or the Master's degree level, who has

had some experience with children in the hospital setting.

Basic Assumptions

(1) Play is an important factor in the development of all children,

but particularly in the therapy for hospitalized children.

(2) The hospitalized child has a need for play activities for

continuation of his normal intellectual, emotional, social

and physical development.

(3) A play activity center staffed by a child development special-

ist would make the hospital stay less traumatic for the child.

Data Secured

Information concerning present play facilities, proposed play

activity centers, and attitudes toward play activity centers and staff

qualifications were collected by means of a mailed questionnaire. Respon-

ses were in five areas:

(1) A description of the pediatric unit.

(2) Descriptions of present play facilities.

(3) Projections of possible additions to play facilities.

(4) Personal opinions of play activity centers.

(5) Personal opinions of the play activity director's role and

training.

Limitations of the Study

The target population was restricted to those general hospitals

in North Carolina which claim to have pediatric units and a total bed

complement of at least 100.

Organization of the Remainder of the Thesis

The problem and purpose of this study was presented in Chapter I.

A review of the literature and recent research in the area of play acti-

vity centers and the hospitalized child will be presented in Chapter II.

Chapter III will include a discussion of procedures used to investigate

the problem. Chapter IV will contain an analysis of the data secured

and a summary and recommendations for further study will be presented

in Chapter V.

CHAPTER II

REVIEW OF LITERATURE

A review of the literature on the hospitalized child and closely

related areas yields sufficient evidence that the ill child confined

within the hospital has special extra-medical needs worthy of the con-

sideration and professional direction of a child development specialist.

Those needs center around the emotional stress under which the hospi-

talized child is placed. This would seem to imply a need for coopera-

tion between medical care and extra-medical services for the treatment

of the child. In an effort to meet these special needs of hospitalized

children, an adequate hospital pediatric program must further consider

those needs consistent with the growth of all children. Cohart (1956-57)

stresses that pediatric workers must not forget about the development of

the whole child in their concern for the treatment of disease.

A further emphasis of the point that the concept of needs of the

ill child is based upon the same principles as those of physically well

children is presented by Robertson (1958) as he stressed a team approach

to the total health of the child. He stated that "If doctors and nurses

are to be more effective in looking after the mental health of young

patients, their training must include the psychological development of

children, coupled with adequate practical experience of normal healthy

young childrenfp. 122]."

A heightening of sensitivity to emotional stress is apparent at

all age levels within the pediatric unit. Although one study (Faust,

Jackson, Cermak, Burtt & Winkley, 1952) has determined that "... the

emotional equipment required for dealing adequately with a hospital

experience, is no different from that needed in dealing with all the

other problems of life Q>. 553," tne factors of physical immobility

or social isolation may be hindering the hospitalized child's adjust-

ment. Langford (1961) stated "The blocking of the normal emotional

discharge channel of motor activity taxes the adaptive capacities of

the child to the utmost [p. 6733."

In support of this observation of the child's increased emotional

stress and apparent confusion during hospitalization, Blom (1958) noted

"A child cannot distinguish between suffering from the illness and the

treatment done for the cure fr>. 592]." Therefore, there appears to be an

important interaction process between the child's concept of his medical

illness and his response to that illness. Blom (1958) recognized the

need for an integration of physical and emotional treatment by stating,

"When the child is hospitalized his fears, anticipations, and concepts

of his medical illness are important not only as psychologic concomitants

but also as they may affect and prolong his illness Qp. 590J."

The Individual child, thus, possesses a unique combination of

adaptive capabilities and adaptation hindrances. He may then have a

wide variety of reactions to this hospital experience. The way a

child reacts to this hospital experience may be dependent upon a number

of variables. These were enumerated by Senn (1945) as:

The physical, intellectual, and psychological status of the individual at the onset of his illness.

The nature of the illness.

The meaning of the illness to the patient.

The Interpersonal relationship of patient and nurse, and of patient and physician. Q>. 25]

Langford (1948) suggested one specific manifestation for Senn's

third variable. He stated, "We can feel sure that in most sick children

there is a certain amount of anxiety because of their ideas as to the

cause of their illness and in many guilty feelings as to their own respon-

sibility Q>. 244]."

Overt reactions to the combination of these variables as they

affect the individual child may or may not be accurate indicators of

his adjustment. Frank (1951) described one reaction which fails to indi-

cate the child's true adjustment: "The quiet child is too frightened to

be able to release his inner tension. His defense mechanism is with-

drawal to a world of fantasy, a much less healthy emotional reaction

than is shown by the child who fights the situation Q>. 326]." She

continued by adding one suggestion for coping with this tension, ex-

plaining that what the child is trying to ask for is "... assurance

that it is all right to be frightened [p. 326]."

Besides withdrawal, another common reaction to hospitalization Is

regression. Langford (1948) described regression as a defense against

anxiety. The strength of this defense is dependent upon the severity

of the emotional disturbance and the length of the illness.

Fear is not an abnormal reaction to the child's entering the

hospital. The reason for this is explained by McComb (1948) in an

article describing a pediatrics program at the University of Michigan

Hospital when he wrote:

The child enters the hospital with multiple fears of treatment, of the unknown, of family separation, and of endless other things. Shyness is an outstanding characteristic. There Is

often an apathetic, negativistic attitude and a very short span of attention. Some children have missed out on whole blocks of normal experience £p. 27].

Davidson (1949) reported a survey of young children in which

the children were asked what they did when something did not go the

way they had wanted or expected. She commented: "The children's

answers indicate their needs to express dissatisfaction in a physical

manner and they all tend toward the aggressive pattern. If this is

a sample of the way a child behaves at home under emotional stress,

what does he substitute in the hospital where tensions are increased

and physical activity is decreased? Qp. 138]"

These reactions do not seem to be restricted to the period of

early childhood. Little (1960) described the normal conflicts of

the adolescent which seem heightened and "Because of the increased

intensity of his impulses he is increasingly aware of his physical

body [_p. 85]." Overt behavior, as is the case in younger children,

is not an accurate indicator of internal feelings or adjustment.

Hollingshead (1960) attributed part of this reaction to the social fac-

tor that the adolescent, "...receives little support because our soci-

ety teaches us to hide our anxieties, especially our fears, for fear

is to be weak, and the weakling is not a hero [p. 134]."

Threatened also in the adolescent is his newly won independence.

Little further observed that cutting down on activity and the restric-

tions which illness is apt to impose may tend to drive the adolescent

into a further state of anxiety because of this increased sensitivity.

One study has been recorded in which the problem of psycholog-

ical upset in hospitalized children was examined by a control method.

10

Sipowicz (1965) used sets of twins, one of which was a Hospitalized

child and one a Home or control child. Judgment of the child's psycho-

logical upset was recorded by the mother after the Hospitalized child

had returned home for a week. The data provided some support for the

principal hypothesis that the combination of hospitalization and illness

is psychologically upsetting for children in general.

Some study has been devoted to the child's reaction to more spe-

cific diseases. These, however, tend to deal less with hospital effects

and more with the characteristics of the illness itself. Dubo (1950)

studied 25 children having pulmonary tuberculosis. Many of these chil-

dren shared common emotional disturbances such as regression, immature

relationships, a preoccupation with death, a tendency to assume personal

responsibility for the illness and attempts to escape reality. These

symptoms were thought to be a result of the specific characteristics of

the disease since there appeared to be no indication of a characteristic

preillness personality pattern among the children. The lack of observable

symptoms made the concept of tuberculosis abstract to the children. The

investigator considered this an ego threatening experience beyond that

which a child suffering from a fracture, burns, measles or some similarly

observable infliction might encounter.

Rheumatic fever has been associated with emotional conflict. Ob-

servations made on these cases (Huse, 1951; Josselyn, 1949; Josselyn, Simon

& Eells, 1955) attributed many of these conflicts to the necessarily ex-

tremely long convalescent period. This period may last several years during

which the young child may be away from home confined to a convalescent

home •

11

Tonsillectomy and surgery are two other main reasons for hospital-

izatlon which have been studied. Coleman (1952) recognized the concern

for the emotional health of the young surgical patient. He said that

neuropsychiatrists, such as himself, "... find that the thoroughly pre-

pared child goes through the entire experience (surgery) with little if

any emotional trauma ^p. 42J." Pillsbury (1951) also stresses adequate

emotional preparation for surgery. As a follow-up of the child's expe-

rience, she suggests "A present of a 'doctor set,' available in many

toy stores, may help him to master his feelings about the experience

through play £p. 124]."

These specific illnesses, although they do not provide a general

projection of the hospitalized child's needs, do serve to illustrate the

need for individual consideration for the individual ill child's emotional

as well as physical needs. An attempt to meet these emotional needs of

hospitalized children is being made through play activity programs estab-

lished in pediatric units.

The value of play to the child has been equated with the achievement

and expressive values of work for the adult. Wessell (1947) in a dis-

cussion of the pediatric nurse and human relationships said, "All

pediatric workers, and nurses in particular, should realize that 'play-

ing is living' [p. 216]." Kangery (1960) described the child's play

as "... a response to his emotional urges and needs [p. 1749J."

This emotional release is used by all children in their normal

developmental pattern. Bakwin (1951), however, perceived the hospi-

talized child as needing a unique program of play designed to meet his

limitations. Mentioning specifically the bed-ridden child he stated:

12

"The child who is confined to bed suffers a great disadvantage in that

he is unable to release pent-up emotions by physical activity [p. 3873."

More specifically, Senn (1945) described emotional aspects of

convalescence with a section on play.

In children, play is a natural medium for communication. It permits a child to tell us things about himself as a person, his physical abilities, and his feelings. It enables him to try out physical energy, to experiment with newly discovered endowments, and at the same time to gain something psycho- therapeutically as he relates his experiences and emotions to others. It brings relaxation and rest, diverts the mind from stress, and acts as a safeguard against the development of undesirable habits such as excessive thumb sucking, master- bation, and daydreaming, through providing opportunity to express tension, anger, and resentment. Opportunities for diversional and occupational play should be provided each child in keeping with his physical, intellectual, and emotional needs. £p. 28J

Communication serves as a means to the specific ends of under-

standing the situation in which one is and being understood in that

situation. Davidson (1948) established this function of play in

adjustment through understanding: "The child who is sick needs play

to understand and adjust to the unfamiliar situation which illness

creates [p. 1723."

Additional references support the values of play for the hospital-

ized child. Besides the values of communication and specific adjust-

ment to a new situation, Richards and Wolff (1940) applied play values

to the child's emotional strain: "Play becomes a safety valve for his

(the child's) hidden wishes and fears and a balance for the tensions that

are a part of every growing child's life. Ill or well the child needs

play [p. 229]."

With an understanding of why the child needs play during his

hospitalization period, more specific objectives for a play program

13

may be examined. Richards and Wolff (1940) suggested a comprehensive

list of objectives for a hospital play program:

To give the child assurance.

To use the long hours of waiting and convalescence in healthy, creative play activities.

To help recondition the child who has learned to fear hospitals and illness.

To furnish a method of observing and evaluating a child's play in relation to the problems of his life.

To educate mothers, fathers, nurses and doctors in the importance and proper use of play. £p. 236-237J

The positive approach to play activity is made by all of the

above objectives. To lessen the child's adverse reaction to the hospital

experience may, in fact, be only part of the broader objective of

assisting in the continuation of the child's normal developmental

pattern. Tisza and Angoff (1957) perceived this developmental pattern

as a determinant of the atmosphere of the total play program. Basing

their theory of play activity on a program established at the Boston

Floating Hospital, they stated: "The freedom and activity of the play-

room places the emphasis on the healthy part of the child Qp. 300]."

Research and pilot programs are being conducted at the Albany

Medical College, Children's Medical Center in Boston, Boston Floating

Hospital, North Carolina Memorial Hospital, and Children's Memorial

Hospital, Chicago, which show an increasing awareness of the value of

play to the hospitalized child. Faust, et. al. (1952) conducted a

study on the child's reaction to anaesthesiology. The results placed

an emphasis on preparation for the hospital experience through helping

the child know what to expect. This includes a modification of the

14

experience which the child has the ability to endure. A further recom-

mendation is that "The young patient should not be required to stay in

bed, especially alone in a room, when he is feeling well. On the day

before surgery, he will be much happier and more cooperative if he is

allowed to go about the ward and play in the company of other children

[p. 59]."

Prugh, Staub, Sands, Kirschbaum and Lenihan (1953) in a short-

term longitudinal project studied the emotional reactions of children

and families to hospitalization at the Children's Medical Center, Boston.

They reported positive effects on the children's reactions under the

experimental conditions of communication, staff support, parental

involvement, and a play program.

Tisza and Angoff (1957) have reported a play program for children

aged two months to eighteen years at the Boston Floating Hospital. As

well as suggesting supervised freedom, results of this program stress

a developmental approach to care and techniques. Cooperation between

hospital staff, volunteers and parents appears to provide the most

workable situation.

A pediatric playroom at the North Carolina Memorial Hospital,

Chapel Hill, has provided an opportunity for medical students to become

aware of the concept of play activity. After his pediatric residency

at this hospital Dr. Griggs C. Dickson reported upon examining another

pediatric department without such facilities (Waddell, 1962):''I found

the lack of playroom facilities disturbing and many children who were

hospitalized for prolonged periods (and even shorter terms) returned

home with many and often serious emotional disturbances [p. 67^."

15

While later observing another hospital with the same lack of play facil-

ities, Dr. Dickson noted, "... that the total hospitalization tended to

be somewhat of a negative experience. A play program, he felt, was a

needed 'plus factor' £p. 68]."

Cassell (1965) experimented with the technique of puppetry as a

preparation for cardiac catheterization at Children's Memorial Hospital,

Chicago. This form of social play activity appeared to have helped the

children "... discriminate the catheterization as a single distressing

experience and therefore feel relatively little anxiety about it after

its completion [p. 7]." The hypothesis that children given the puppet

therapy would show less emotional disturbance during the cardiac catheter-

ization was supported.

An examination of the literature reveals the special problems

and needs of the hospitalized child. The value of play to the hospi-

talized child is also recognized. Use of play techniques in the pedi-

atric unit appears to be meeting many of these special needs in

experimental projects and pilot programs of play activity centers.

16

CHAPTER III

PROCEDURES

The concept of play activity centers Is recorded in the liter-

ature as a contributing factor to the hospitalized child's development

and emotional well being. This study is concerned with the application

of this concept within the pediatric units of North Carolina hospitals.

To achieve the purpose of this study four steps were followed: (1) the

development of a questionnaire; (2) the determination of the general

hospital population; (3) the determination of the target population

of hospitals with pediatric units; and, (4) distribution of the ques-

tionnaire to the pediatric unit target population.

Development of the Questionnaire

There was no available instrument by which a survey of play ac-

tivity centers could be made. A twenty-item questionnaire was developed

by the investigator. (See Appendix D) The information to be collected

by this questionnaire concerned present play facilities, proposed play

activity centers, and play activity staff qualifications and responsi-

bilities.

Questions involved responses in five areas:

A description of the pediatric unit.

Descriptions of present play facilities.

Projections of possible additions to play facilities.

17

Personal opinions of play activity centers.

Personal opinions of the play activity director's role and training.

Determination of the General Hospital Population

The target population was to include all general hospitals in

North Carolina claiming to have a pediatric ward, unit or separate

area for pediatric beds. There was no available listing of North Caro-

lina hospitals with pediatric units. A complete listing of non-federal

North Carolina hospitals as of March 1, 1968 compiled by the North

Carolina Medical Care Commission was used as a locating source for the

target population. From this list, all general hospitals with a bed

complement of 100 or more were selected as possibly meeting the cri-

terion of having a pediatric unit. There was a total of 70 general

hospitals having a bed complement of 100 or more.

Determination of the Target Population

A letter was sent by the investigator to the administrator of

each of the 70 hospitals having a bed complement of 100 or more. (See

Appendix B) The administrators were asked to check on a return postal

card whether or not their hospital had a pediatric unit.

Thirty-two administrators indicated that their hospital did

have a pediatric unit. These 32 hospitals comprised the target popu-

lation. (See Appendix A)

,

■^-

18

Distribution of the Questionnaire

The respondents in the survey were divided into three categories:

(1) hospital administrators; (2) staff pediatricians; and (3) pediatric

nurses. Three questionnaires and three self-addressed, stamped envelopes

were mailed to the administrators of each of the 32 hospitals in the target

population. Each administrator was then asked to complete one of the

questionnaires and to distribute a questionnaire to both a staff pedi-

atrician and a pediatric nurse. All respondents were asked to complete

the questionnaires independently and return them directly to the inves-

tigator. The total number of questionnaires distributed was 96.

Treatment of the data from the questionnaires will be discussed

in Chapter IV.

s

19

CHAPTER IV

ANALYSIS OF THE DATA

The purpose of this study was to survey by means of a mailed

questionnaire the North Carolina hospitals claiming to have a pedi-

atric unit. Responses to the questionnaire provided information

about present play facilities, proposed play activity centers, and

staff qualifications and training. Comparisons of the responses of

hospital administrators, pediatricians and pediatric nurses were

made to test the two hypotheses:

I. There will be no difference in the acceptance of play

activity centers among pediatric nurses, pediatricians

and hospital administrators.

II. There will be no difference in the perceived need for

trained personnel for play activity centers among

nurses, pediatricians and hospital administrators.

Data Collection

Three questionnaires with stamped envelopes for return mailing

were sent to the administrators of those 32 hospitals which claimed

to have a pediatric unit. The administrators were then asked to keep one

questionnaire and distribute one copy to a staff pediatrician and one

to a pediatric nurse. The three respondents from each hospital were

then asked to complete the questionnaires independently and return

20

them directly to the investigator. The total number of questionnaires

distributed was 96.

A total of 63 questionnaires was returned to the investigator.

This represented a 65.67. return. Twenty-five of the 32 hospitals in

the target population or 78.1% were represented in the collected data.

Those 17 hospitals returning a completed set of three questionnaires

represented 53.1% of the total 32 hospital target population. A com-

pilation of the percentage return is presented in Table 1.

Table 1

Percentage Distribution of Returned Questionnaires

Dis tribi ted Returned Per Cent Re turned

Total 96 63 65.6

Hospitals Represented 32 25 78.1

Hospitals with a set of 3 returned 32 17 53.1

Administrators 32 22 68.8

Pediatricians 32 19 59.4

Pediatric Nurses 32 22 68.8

Reliability of the Questionnai re

To determine the reliability of the questionnaire a comparison

of certain factual questions asked of the respondents was made.

These comparisons were made between respondents from the same hospital

21

and were also intended to assess the degree of awareness of the pediatric

unit by the three classes of respondents. Questions selected were: (See

Appendix D)

(2) Size of the pediatric unit.

(5) Usual number of ambulatory pediatric patients who might be

able to participate in a play situation.

(6) Parent visitation hours in the pediatric unit.

(7) or (8) Response to (7) indicating a playroom. Response to

(8) indicating no playroom facility in that hospital.

(lO)School or teaching service available for the school-aged

children.

(ll)Whether the pediatric unit does or does not have access to

a volunteer program.

A survey of the questionnaire within the individual hospital

sets revealed very little variance in responses of administrators,

pediatricians and nurses. Percentages of agreement were: (1) question 2:

857.; (2) question 5: 607.; (3) question 6: 607.; (4) question 7 or 8: 1007.;

(5) question 10: 607.; and (6) question 11: 857.. A possible reason for

lower agreement on the number of ambulatory patients able to participate

in a play activity oenter was the opinion nature of the question. The

respondent classes were asked to make an estimate of the usual number

of possible participants. Questions concerning visitation hours and

teaching services having an agreement of 60% among the three respondent

classes each had an 85% and 100% agreement respectively between two

of the three respondents in each hospital set. The questionnaire was

then assumed to be sufficiently reliable without more formal reliability

-

22

testing. The respondents in the three classes were also assumed to be

sufficiently aware of conditions within their respective pediatric units

to permit meaningful comparisons of their responses.

Analysis of the Data

Because the total target population was used instead of a random

sample of pediatric units, percentage of response was the technique used

to analyze the data. As a result of the finite population studied, addi-

tional statistics could not be used to test the hypotheses. The results

of the percentage analysis will be discussed on the descriptive level,

pointing out trends toward agreement among respondent classes.

Responses could not be matched within hospital sets because the

25 hospitals represented did not return completed sets of questionnaires.

Therefore, questions concerning the actual organization of individual

pediatric units were not of value in the testing of the two hypotheses

of this study. Opinion questions were selected to test the hypotheses

and a discussion of them follows in the next two sections.

Hypothesis I

Hypothesis I states that: There will be no difference in the

acceptance of play activity centers among pediatric nurses, pediatri-

cians and hospital administrators.

Questions which were designed to indicate the acceptance of play

activity centers were 7(a); 7(b); 8(a); 8(c); 8(f); and 9. (See Tables

2,3,4,5,6 and 7)

Questions 7(a), "In your opinion, is this play activity center of

23

value to the pediatric unit in your hospital?", and 7(b) concerning

needs for a director of the existing play activity center were answered

only by those staff members whose hospital does have a separate playroom

for children. Responses are shown in Tables 2 and 3.

Table 2

Analysis of Responses to the Question: "In your opinion, is this play

activity center of value to the pediatric unit in your hospital?"

Respondent N Raw Data Per Cent

Administrator 15

13

13

15 yes

13 yes

13

0 100 yes

100 yes

100 yes

0

Pediatrician

no

0

no

0

Nurse

no

0

no

0 yes no no

This question of play activity value to the pediatric unit sup-

ports Hypothesis I and indicates no difference in the acceptance of

existing play activity centers. There was complete agreement among

the three classes of respondents.

^

24

Table 3

Analysis of the Responses to the Question of Requirements For a Play Activity

Director in Existing Play Activity Centers

Adminis- Pedia- Response trator trician Nurse

N-15 N-13 N=13

60.07. 46.2% 30.8%

6.7% 38.5% 15.4%

0.0% 0.0% 0.0%

20.0% 7.7% 23.1%

13.2% 7.7% 30.8%

No director and a part time program.

A part time director and a part time program.

A part time director and a full time program.

A full time director and a full time program.

Other

The question of need for a play activity director has been answered

partially as a factual question indicating existing facilities and partially

as an opinion of the needs for a director and program. Differences are in-

dicated in every case except the agreement by all respondent classes that

there was no need for a part time director and a full time program.

Answered by respondents in hospitals not having playroom facilities

were: 8(a) "In your opinion, would a play activity center be of value to

the pediatric unit of your hospital?"; 8(c) "Would you consider converting

this space into a playroom?"; and, 8(f) concerning play activity director

requirements to fit the needs of the pediatric unit. Responses are shown

in Tables 4,5 and 6.

Table 4

Analysis of the Responses to the Question: "In your opinion, would a play activity

center be of value to the pediatric unit of your hospital?"

25

Respondent N Raw Data Per Cent

Adminis trator

Pediatrician

71.4 28.6

Nurse

6

yes

2

no

4 no

1

yes

33.3 yes

88.9 yes

no

66.7

9

yes

8

no

11.1 yes no no

This question of play activity center value fails to support

Hypothesis I although both nurses and administrators show a majority

of acceptances to the establishment of a play activity center.

Table 5

Analysis of the Responses to the Question: "Would you consider converting this

space into a playroom?"

Respondent N Raw Data Per Cent

Administrator 6

5

4

2 4 33.3 yes

20.0 yes

50.0 yes

66.7

Pediatrician

yes

1

no

4

no

80.0

Nurse

yes

2

no

2

no

50.0 yes no no

26

The question of conversion of space to a playroom shows no support

for Hypothesis I and little trend of agreement among the three classes of

respondents.

Table 6

Analysis of the Responses to the Question of Requirements For a Play Activity

Director to Fit Pediatric Unit Needs

Adminis- Pedia- Response trator

N=6 trician

N-3 Nurse

N-5

No director and a part time program. 33.37. 0.07. 20.07.

A part time director and a part time program. 50.0% 100.07. 60.07.

A part time director and a full time program. 16.77. 0.07. 20.07.

A full time director and a full time program. 0.07. 0.07. 0.0%

Other 0.07. 0.07. 0.07.

Response to the question of need for a play activity director

indicates agreement on the lack of need for a full time director and a

full time program in a play activity center. There is also agreement

upon no alternative program, or the "Other" response. There is also

agreement between nurses and administrators on a need for a part time

director and a full time program.

Question 9, "What, in your opinion, is the most important value

of a play activity center?", indicated the acceptance of play activity

27

centers by presenting a list of values suggested in the literature as

applying to hospital playroom programs. The responses are indicated

in Table 7.

Table 7

Analysis of the Responses to the Question: "What, in your opinion, is the most

important value of a play activity center?"

Adminis- Pedia- Value trator trician Nurse

N-20 N.16 N-17

0.07. 6.37. 0.0%

40.0% 25.07. 11.8%

5.07. 18.87. 11.8%

0.07. 0.07. 0.0%

5.07. 0.0% 5.9%

0.0% 6.37. 0.0%

50.07. 43.8% 70.6%

None

Entertainment

Supervised Play

Education

Motor Coordination and Development

Social Interaction

Reduction of Emotional Stress

Responses to the question of the most important value indicate

support for Hypothesis I with regard to an agreement in the value of

"Education" in the play activity center. Agreement between the adminis-

trators and nurses with regard to values "None" and "Social Interaction"

is indicated. All three classes of respondents indicate the most often

selected value is "Reduction of Emotional Stress."

28

Hypothesis II

Hypothesis II states that: There will be no difference in the

perceived need for trained personnel for play activity centers among

nurses, pediatricians and hospital administrators.

Questions included on the questionnaire which were designed to

test Hypothesis II were 18, 19 and 20. Tables 8,9, 10, 11, 12, 13,

14 and 15 indicate an analysis of the data.

Question 18 asked the respondents to "Rank in 1,2,3 etc. order

the following training backgrounds for a play activity center director

from the most desired (1) to the least desired (6)." Because of the

ranking nature of the question, two techniques were used to examine

responses to this question. The first of these methods was to assign

each rank from one to six with a rank value. Integers from one to

six were assigned consecutively to the ranks from six to one as rank

values. Thus, a rank of one, or the most desired training for a play

activity director was assigned a rank value of six. The least desired

training was assigned a rank value of one. Appendix E shows the raw

data obtained from question 18, ranking of desired training, responses.

The number of responses multiplied by rank value was added to the

remaining responses multiplied by their rank value in each individual

training type. The sum of these responses multiplied by rank values

equals a total value for each training type. Table 8 shows the rank

for each training type when the sums are arranged sequentially from

greatest to least value.

Table 8

Rank of Preferred Training For Play Activity Directors

29

Rank Administrators Pediatricians Nurses

1

2

3

4

5

6

Child Development Child Development

Psychology Teacher

Teacher Psychology

Nursing Social Work

Social Work Nursing

Any Major Any Major

Child Development

Psychology

Teacher

Nursing

Social Work

Any Major

The ranking assigned by administrators and nurses was identical

when responses were considered in this collective manner. Pediatricians,

however, assigned a different rank order except in the cases of the

most preferred training, "Child Development," and the least preferred

training, "College Degree - Any Major."

A percentage analysis was made of each training type. The break-

down of responses to ranking as applied to each training type is shown

in Appendix F. The basic trend of ranking "Child Development" as the

most preferred and "College Degree - Any Major" as least preferred

is indicated. (See Tables 9 and 10)

30

Table 9

Percentage Analysis of the Most Preferred Play Activity Director Training Type-

Child Development

Rank Administrator Pediatrician Nurse N-19 N-ll N-15

1 68.47. 81.87. 66.77.

2 26.3% 9.17. 26.77.

3 5.37. 9.17. 6.77.

4 0.0% 0.07. 0.0%

5 0.07. 0.07. 0.0%

6 0.07. 0.07. 0.0%

Trends toward ranking "Child Development" as first by all

respondent classes are indicated by the figures in Table 9. No

responses less than a rank of three are reported. Closest agreement

is between administrators and nurses. Pediatricians, however, show

an even greater tendency than the other two classes to rank "Child

Development" as most preferred.

31

Table 10

Percentage Analysis of che least Preferred Play Activity Director Training Type-

College Degree - Any Major

Rank Administrators N.19

Pediatricians fell

Nurses N.1.5

P. 07.

0.07.

0.07.

5.31

21.1%

73.7%

0.07.

0.07.

9. IX

45.51

9. IX

36.4X

o.ox

o.ox

o.ox

6.7X

40. OX

53.3X

Figures in Table 10 indicate the trend to rank "College Degree-

Any Major" as the least preferred play activity director training.

Pediatricians were the only class to rank "Any Major" above the rank of

four. The table indicates that 9. IX of the pediatricians ranked "Any Major"

as third and the largest per cent ranked it as fourth while the largest

per cent of administrators' and nurses1 responses were a rank of six.

The responses of an intermediate rank for preferred training are

shown in Appendix F.

Question 19 asked: "Rank in 1,2,3 etc. order the following types

of experience which you feel are most desirable (1) to Uast desirable

(5) for a play activity director." Since experience is often considered a

vital part of formal or informal training, question 19 was included to

investigate opinions of desired experience for play activity directors.

32

The same two treatments which were applied to question 18 were used

to analyze the data from question 19.

The figures in Appendix G indicate the sum totals of rank mul-

tiplied by rank value, assigned one through five, for each type of

experience by each class of respondents. Table 11 represents a sequen-

tial assignment of total values obtained for each experience type by

the three respondent classes.

Table 11

Rank of Preferred Experience of Play Activity Center Directors

Rank Administrators Pediatricians Nurses

Nursery School

Hospital

School or Clinic for Exceptional Children

Public School

None

Nursery School

Hospital

Public School

School or Clinic for Exceptional Children

None

Nursery School

School or Clinic for Exceptional Children

Hospital

Public School

None

A percentage analysis of the preferred experience is shown in Ap-

pendix H. Each sub-chart includes data for the separate experience type.

Table 12 is a compilation of the first ranked or most preferred play

activity director experience.

Table 12

Percentage Analysis of the Most Often Preferred Play Activity

Director Experience

33

Experience Adminis- trator

Pedia- trician

Nurse

None

Public School

Nursery School

School or Clinic for Exceptional Children

Hospital

0.0% 7.1% 0.0%

5.07. 14.3% 17.6%

35.0% 35.7% 52.9%

30.0% 0.0% 11.8%

30.0% 42.9% 17.6%

From Table 12 the trend is toward ranking "Nursery School" expe-

rience by administrators and nurses, although the administrators also

ranked "Hospital" and "School or Clinic for Exceptional Children" as

preferred choices of experience. Pediatricians ranked "Hospital" expe-

rience as most preferred, but a large per cent agreed with the "Nursery

School" experience preference.

Question 20: "Place a check (•} to the left of the three things

you consider the most important aspects of a play activity center direc-

tor's role. Draw a line through any you feel should not be the respon-

sibility of the play activity center director," is a more indirect ap-

proach to the testing of Hypothesis II. The role or responsibilities

assigned to a play activity director are assumed to indicate the need

for a particular type of training desired by the respondent. The figure.

in Appendix I indicate the frequency with which a particular type of

34

responsibility was selected as one of the three most important aspects

of a play activity director's role.

An examination of Appendix I shows a difference among opinions

of the three classes of respondents in every case except that of "Attend

designated pediatric staff meetings." Five other cases indicate simi-

larities of the responses of two of the three classes. A trend of the

classes of respondents toward responsibilities is presented in Tables

13, 14 and 15.

Table 13

The Three Most Often Selected Role Aspects By Administrators

Rank Per Cent Aspect of the Director's Role

1 100.0 Schedule activities for the play activity center.

2 72.2 Make policies and set regulations for play activity with the cooperation of the medical staff.

3 38.9 Direct volunteer aid (train and schedule).

I

35

Table 14

The Three Most Often Selected Role Aspects By Pediatricians

Rank Per Cent Aspect of the Director's Role

93.8 Schedule activities for the play activity center.

87.5 Make policies and set regulations for play activity center with the cooperation of the medical staff.

50.0 Direct volunteer aid (train and schedule).

Table 15

The Three Most Often Selected Role Aspects By Nurses

Rank Per Cent Aspect of the Director's Role

83.3 Schedule activities for the play activity center.

50.0 Make policies and set regulations for play activity center with the cooperation of the medical staff.

44.4 Select Equipment.

The above three tables indicate a trend toward similar ideas of the

play activity director's role. These role expectations should, in turn,

indicate the areas of training needed in developing competent play activity

directors. Support for Hypothesis II was not indicated by analysis of

the first part of question 20 concerning role expectations.

In Appendix J there is a compilation of the data from the second

36

part of question 20: Draw a line through any you feel should not be

the responsibility of the play activity center director." Total

agreement on three of the responsibilities was indicated. These three

were all a result of no negative response to:(l) Make policies and set

regulations for play activity center with the cooperation of the medical

staff; (2) Select equipment; and, (3) Schedule activities for the play

activity center. Trends toward agreement were again indicated for

Hypothesis II, but no conclusive support was evident.

In this chapter an analysis of questionnaire data has been pre-

sented. The only conclusive support for Hypothesis I was shown by

responses to question 7(a) which indicated an agreement of the value

of existing play activity centers by administrators, pediatricians and

nurses. Trends were shown toward agreement among the three classes of

respondents with regard to both hypotheses.

The final chapter will include a summary of the study, conclu-

sions drawn from the data and recommendations for further study.

37

CHAPTER V

SUMMARY, CONCLUSIONS AND RECOMMENDATIONS

The purpose of this study was to compare the responses of three

classes of respondents, hospital administrators, staff pediatricians

and pediatric nurses. A survey was made of existing play activity

centers in North Carolina general hospitals. In addition to examining

present play facilities in pediatric units, members of hospital staffs

were surveyed to investigate their opinions of hospital play facilities

and their understanding of the play program concept. This comparison

was designed to examine the uniformity of understanding of the play

activity concept among members of the total pediatric staff.

Assumptions of the value of play for both the well and the ill

child were made. A number of reports from the literature and recent

research articles supported the need for an understanding of the specific

needs of the ill child and consideration for the normal developmental

process during illness and hospitalization.

Blom (1958) recognized the need for an integration of physical

and emotional treatment by stating, "When the child is hospitalized

his fears, anticipations, and concepts of his medical illness are im-

portant not only as psychologic concomitants but also as they may affect

and prolong his illness [p. 590]." Adding to the emotional stress of

illness is the restriction of a means of discharging the hospitalized

child's anxiety. Langford (1961) stated : "The blocking of the normal

emotional discharge channel of motor activity taxes the adaptive •

38

capacities of the child to the utmost£p. 673^." The literature contains

reference to the concept of play activity as emotionally and physically

therapeutic. Wessell (1947) in a discussion of the pediatric nurse and

human relations said, "All pediatric workers, and nurses in particular,

should realize that 'playing is living' Qp, 2161." Kangery (1960) de-

scribed the child's play as "... a response to his emotional urges and

needs [ p. 174931." Richards and Wolff (1940) applied play values to the

child's emotional strain and said, "111 or well the child needs play

[p. 2293." Research studying the idea of play activities for the hospi-

talized child such as that by Faust, et. al. (1952) at the Albany

Medical College and Cassell (1965) at Children's Memorial Hospital,

Chicago, supports the value of play and the special and developmental

needs of the hospitalized child.

A 20-item questionnaire was developed by the investigator to use

as a tool for surveying hospital administrators, pediatricians and

pediatric nurses. The questionnaire was distributed to 32 general

hospitals in North Carolina which claimed on a pre-survey to have a

pediatric unit. Three questionnaires were completed independently by:

(1) the hospital administrator; (2) a staff pediatrician; and, (3) a

pediatric nurse, and were returned directly to the investigator.

The number of questionnaires returned was 63, which is 65.6%.

This return represented 78.17. of the hospitals with 53.1% of the

hospitals returning a complete set of three questionnaires.

Data collected on the questionnaires were analyzed using per-

centage of the responses. Questions concerning opinions were selected

to test the two hypotheses:

39

Hj: There will be no difference in the acceptance of play

pediatrii pediatricii activity centers among

and hospital administrators.

HJJ: There will be no difference in the perceived need for

trained personnel for play activity centers among nurses,

pediatricians and hospital administrators.

Hypothesis I was supported by responses to one question: 7(a)

"In your opinion, is this play activity center of value to the pediatric

unit in your hospital?" Yes responses from all three classes of respondents

totaled 1007.. Trends toward similar acceptance of play activity centers by

administrators, pediatricians and nurses were noted in the data analysis.

The data, however, did not conclusively support the null hypothesis.

There was no conclusive support for Hypothesis II in the data

analyzed. There were, however, trends developing toward similar concep-

tions of the need for trained personnel in play activity centers. This

was reflected in the type of training desired and responsibilities desig-

nated to a play activity director. Similar trends also formed in the

types of experience preferred by the three classes of respondents.

Conclusions

Although the null hypotheses were not conclusively supported, the

data does point to some of those areas in which pediatric staff members

are in partial agreement. Of those hospitals which reported an existing

play activity center there is a 100% agreement of the value of this

center. Agreement of the value of a play activity center is very slight

among the respondent classes in those hospitals not having play /

40

facilities. This could be a result of a lack of understanding on the

part of the respondents with regard to the functioning and purpose of

play activity centers in those hospitals not actually having one.

Differentiated opinion could be a result of the amount of time actually

spent interacting with the patients and parents involved. A third pos-

sibility could be positive or negative previous experience with a more

or less adequately staffed and directed play activity center. A further

possibility could be that those hospitals not having a play activity

center could have space too limited to consider any value in a play-

room addition at this time, or that there are too few pediatric beds

to permit inclusion of a pediatric play activity center.

The largest percentage of respondents in all classes selected

"Reduction of Emotional Stress" as the most important value of a play

activity center. This closely correlates with values reported in the

literature. The least often selected play activity center value was

"Education."

There was a trend toward agreement in the training preferred by

the largest percentage of respondents for a play activity center director,

"Child Development." All classes agreed with this preferred training.

"College Degree - Any Major" was least preferred as training for a play

activity director. Agreement was noted in the preferred rank order

by administrators and nurses. A percentage analysis of the data did not,

however, show this preference for training as identical.

"Nursery School" was the preferred type of experience by all

classes of respondents. Least preferred by all classes was "None."

Further agreement in ranking was only slight when comparing the three

41

respondent classes.

A trend toward agreement of the play activity director's role was

indicated. Similar combinations of most important role aspects were in-

dicated by the responses from all three respondent classes.

In summary, there was no conclusive support for the null hypotheses.

The degree of agreement between hospital administrators, pediatricians and

nurses did indicate a trend in acceptance of play activity centers, and in

the understanding of the values of play for the hospitalized child and in

the role of the director of a play activity center. The value of the

survey, thus, may lie in the trends toward preferred training experience,

preferred values and role expectations and the similarities of the responses

from members of the pediatric staff rather than in the percentage analysis

of the data. The hypotheses then become guides to the description of the

accepted play activity center concept and its potential development

instead of points of statistical difference.

Recommendations For Further Study

The investigator recommended that further study be conducted after

a program of education concerning the purposes and values of play activity

centers. This program could be carried out by articles in the professional

journals of hospital administrators, pediatricians and nurses. Newsletters

from an established play activity center could also be used for educational

purposes.

A study of the economic feasibility of play activity centers in

small or medium sized hospitals would be of interest. This would include

design of room space and utilization of available personnel as directors.

^—

42

Increased child development training for student nurses and use of the

play activity center as an experience laboratory or development of a

training program for volunteers are two suggestions for providing

adequately trained personnel.

■■

43

BIBLIOGRAPHY

Bakwin, H. The hospital care of infants and children. The Journal of Pediatrics, 1951, 39, 383-390.

Blom, G.E. The reactions of hospitalized children to illness. Pediatrics, 1958, 22, 590-600.

Cassell, S. Effect of brief puppet therapy upon the emotional responses of children undergoing cardiac catheterization. Journal of Consulting Psychology, 1965, 29, 1-8.

Cohart, E.M. Where to turn for help with the convalescent child. Child Study, 1956-57, 34 (Winter), 20-23.

Coleman, L.L. Science says - Children need preparation for tonsillectomy. Child Study, 1952, 29 (2), 18-19.

Davidson, E.R. Children's work and play experiences...in hospitals. Childhood Education, 1948, 25, 172-174.

Davidson, E.R. Play for the hospitalized child. The American Journal of Nursing, 1949, 49, 138-141.

Dubo, S. Psychiatric study of children with pulmonary tuberculosis. American Journal of Orthopsychiatry, 1950, ^0, 520-527.

Faust, O.A., Jackson, K., Cermak, E.G., Burtt, M.M., & Winkley, R. Reducing emotional trauma in hospitalized children. Albany Research Project, Albany Medical College, New York, Oct. 1, 1952.

Frank, R. The frightened child. The American Journal of Nursing, 1951, 51, 326-328.

Hollingshead, A.B. A sociologic perspective on adolescence. Pediatrlc Clinics of North America , I960, 7(1), 131-145.

Huse, B. Rheumatic fever and the child's emotions. The Child, 1951, .16, 3-4.

Josselyn, I.M. Emotional implications of rheumatic heart disease ^chil- dren. American Journal of Orthopsychiatry , 1949, 19, 87-100.

Josselyn, I.M., Simon, A.J., &Eells, E. Anxiety in children convalescing from rheumatic fever. American Journal of Orthopsychiatry, 1955, 25, 109-117.

-i

44

Kangery, R.H. Children's answers: How it feels to be in a hospital. The American Journal of Nursing. 1960, 60, 1748-1751.

Langford, W.S. Physical illness and convalescence: Their meaning to the child. The Journal of Pediatrics, 1948, 22> 242-250.

Langford, W.S. The child in the pediatric hospital: Adaptation to illness and hospitalization. American Journal of Orthopsychiatry, 1961, 31, 667-684.

Little, S. Psychology of physical illness in adolescents. Pediatric Clinics of North America, 1960, ]_(l), 85-96.

McComb, E. To learn to laugh. Recreation, 1948, 42, 27-29.

Pillsbury, R.M. Children can be helped to face surgery. The Child, 1951, 15, 122-124.

Prugh, D., Staub, E.M. , Sands, H.H., Kirschbaum, R.M., & Lenihan, E.A. A study of the emotional reactions of children and families to hospitalization and illness. American Journal of Orthopsychi- atry, 1953, 22, 70-106.

Richards, S.I. & Wolff, E. The organization and function of play activities in the set-up of a pediatric department. Mental Hygiene, 1940, 24, 229-237.

Robertson, J. Young children in hospitals. New York: Basic Books, 1958.

Senn, M.J.E. Emotional aspects of convalescence. The Child, 1945, 2£. 24-28.

Sipowicz, R. & Vernon, D. Psychological responses of children to hospi- talization. American Journal of Diseases of Children, 1955, 109(3), 228-231.

Tisza, V.B. & Angoff, K. A play program and its function in a pediatric hospital. Pediatrics, 1957, .19, 293-302.

Waddell, A.C. Play therapy does the trick. The Triangle of Sigma Sigma Sigma, 1962, 62, 67-68.

Wessel, M.A. The pediatric nurse and human relations. The American Journal of Nursing, 1947, 47, 213-216.

45

APPENDIX A

General Hospitals in North Carolina

With a Bed Complement of 100

or Greater and Claiming

To Have A Pediatric

Unit

46

HOSPITAL LOCATION REPRESENTATION IN RESPONSES

1. Cape Fear Valley Hospital Unit

Fayetteville, N.C. * * *

2. Charlotte Memorial Unit

Charlotte, N.C. * * *

3. Cleveland Memorial Hospital

Shelby, N.C. *

4. Duke University Medical Center

Durham, N.C. * * *

5. Forsyth Memorial Hospital

Winston-Salem, N.C.

6. Grace Hospital Morganton, N.C. * * *

7. Hamlet Hospital Hamlet, N.C.

8. Haywood County Hospital

Waynesville, N.C. * * *

9. Johnston Memorial Hospital

Smithfield, N.C. * * *

10. Kate Bitting Reynolds Memorial Hospital

11. Lenoir Memorial Hospital

12. Margaret R. Pardee Memorial Hospital

13. Memorial Mission Hospital of Western North Carolina

14. Moore Memorial Hospital

15. Moses H. Cone Memorial Hospital

16. New Hanover Memorial Hospital

Winston-Salem, N.C.

Kinston, N.C.

Hendersonville, N.C.

Asheville, N.C.

pinehurst, N.C.

Greensboro, N.C.

Wilmington, N.C.

* * *

* * *

* * *

47

HOSPITAL LOCATION REPRESENTATION IN RESPONSES

17. North Carolina Baptist Hospital

18. North Carolina Memorial Hospital

19. Park View Hospital

20. Pitt County Memorial Hospital

21. Presbyterian Hospital

22. Randolph Hospital

23. Rex Hospital

24. Rowan Memorial Hospital

25. Rutherford Hospital

26. Scotland Memorial Hospital

27. Wake Memorial Hospital

28. Watts Hospital

29. Wayne County Memorial Hospital

30. Wesley Long Community Hospital

31. Wilkes General Hospital

32. Wilson Memorial Hospital

Winston-Salem, N.C.

Chapel Hill, N.C.

Rocky Mount, N.C.

Greenville, N.C.

Charlotte, N.C.

Asheboro, N.C.

Raleigh, N.C.

Salisbury, N.C.

Rutherfordton, N.C.

Laurinburg, N.C.

Raleigh, N.C.

Durham, N.C.

Goldsboro, N.C.

Greensboro, N.C.

North Wilkesboro, N.C.

Wilson, N.C.

* * *

* *

* * *

* * *

*

* * *

* * *

* *

* * *

* * *

* *

* *

* * *

48

APPENDIX B

Letter and Postal Card to the

Administrators of All North

Carolina General Hospitals

With a Bed Complement

of 100 or More

49

January 7, 1969

Dear Director:

I am a graduate student in the School of Home Economics at the University of North Carolina at Greensboro. As a part of my Master's thesis I am conducting a survey of hospitals in North Carolina which have pediatric wards or a unit in some way separated from other ward areas. Each hospital is being sent three copies of a questionnaire developed for this survey. The three copies are to be completed independently by (1) the hospital administrator; (2) a staff pediatrician; and, (3) the head pediatric nurse. Questions concern play activities for children within the pediatric unit. No more than fifteen minutes of each's time will be needed to respond and materials may be returned in a provided stamped envelope.

If your hospital does have some kind of separate pediatric area, would you please indicate your willingness to cooperate with the survey and to dis- tribute the sets of materials by completing and returning the enclosed pos- tal card. When I receive your card, I will send three questionnaires to the name and address indicated.

Results of the study will be available to all respondents at the close of the study which should be in the summer of 1969.

Thank you very much for your cooperation and assistance.

Yours truly,

Nancy Coghill Graduate Student

Helen Canaday, Advisor Associate Professor Home Economics

50

Name

Addre ss

(City) (Zip Code)

Please send me 3 sets of materiaLs.

We will not be able to assist you with your survey because we do not have a separate pediatric ward or unit.

APPENDIX C

51

Letters to the Administrators

of All Hospitals in the

Target Population

52

To the Administrator:

Thank you for your cooperation in my study of pediatric play activity centers. Enclosed are the sets of materials you requested. Your help in completing one questionnaire and dis- tributing two sets to (1) a staff pediatrician, and (2) the head pediatric nurse is certainly appreciated.

I look forward to sharing the results of this study with you and your pediatric staff.

Yours truly,

Nancy Coghill Graduate Student

Enclosures

53

APPENDIX D

Questionnaire

54

On the following five pages is a questionnaire which is being distributed to North Carolina hospitals with pediatric units. The questionnaire has been prepared as part of a graduate thesis at the University of North Carolina at Greensboro. The thesis will investi- gate the value and availability of play activity in pediatric units. All information will be treated confidentially.

Answer all questions by placing a check (/) by the answer which most nearly matches your opinion or most accurately defines the pedi- atric unit in your hospital. I would appreciate your completing the questionnaire independently.

Using the prepared envelope, please return this entire question- naire as soon as possible.

Begin by completing the following necessary information.

a. Person completing the questionnaire:

_Administrator Doctor Nurse

b. Name of Hospital _

c. I would be interested in receiving a summary of the completed project.

yes no

55

A

1. Does your hospital have a pediatric ward, or a separate division for pediatric beds?

ye 8 no

2. If the answer is y^s, check the size of the pediatric unit.

0-10 Beds

11-20 Beds

21-30 Beds

31-40 Beds

41-50 Beds

51-60 Beds

61 or over beds

yes no 3. Are the hospitalized children separated by ages?

4. If the anewer to #3 is yes., check the divisions.

Crib Babies

Toddlers (up to age 3 years)

Preschool and Kindergarten (3-5 years)

School-age children under 13 years

^^^ Teenage children

Other. Describe:

5. Usual number of ambulatory pediatric M£M*» 1*t * •"• to participate in a play situation. (Estimate)

0-10

11-20

21-30

31-40

41-50

51-60

61 or over

56

6. What are your parent visitation hours in the pediatric unit?

1 Hour/day 2-4 Hours/day 4-6 Hours/day 8-12 Hours/day

12-16 Hours/day 16-20 Hours/day Rooming-in

7. If you have a separate playroom for the children, please answer the following questions:

(a)

(b)

In your opinion, is this play activity center of value

to the pediatric unit in your hospital? yes no

To fit your pediatric unit needs for a director* of this

center, does your set-up require:

*Note: Play Activity Center Director refers to a teacher-director whose responsibility it is to plan and carry out the play program.

No director and a part-time program.

A part-time director and a part-time program.

A part-time director and a full time program.

A full- time director and a full-time program.

Other. Describe:

8. If you do not have a separate playroom for the children, please answer the following questions:

(a) In your opinion, would a play activity center be of value

to the pediatric unit of your hospital? __

(b) Could space be provided or made available for a play program

or playroom in your pediatric unit? _—

57

(c)

(d)

(e)

(f)

Would you consider converting this space into a playroom?

yes no Would a playroom in your pediatric unit warrant a change

in your parent visitation hours? yes no

If the answer to question (d) is yes, would you establish

, visiting hours? and Why? more fewer

If a play activity center were established on your pediatric

unit, to fit the needs for a director* of this center would

your set-up require:

*Note: Play Activity Center Director refers to a teacher-director whose responsibility it is to plan and carry out the play program.

No director and a part-time program.

A part-time director and a part-time program.

A part-time director and a full-time program.

A full-time director and a full-time program.

Other. Describe:

9. What, in your opinion, is the most important value of a play activity center?

None

Entertainment

Supervised

Education

Motor coordination and development

Social Interaction

Reduction of emotional stress

10. is there a school or teaching service available for the school-age

children? -JJ- no

58

11. Does your pediatric unit have access to a volunteer program?

yes no 12. If the answer to #11 Is yes, describe the program briefly:

13. Do you provide room television for all children?

14. Are televisions available to rent?

15. Do you have a children's book shelf or lending library?

yes

yes

no

no

yes no Do you have access to a collection of children's books?

yes no 16. If your hospital has a playroom, are meals served to the children

there? yes no

17. Do you have any of the following people readily available to assist on the pediatric unit?

Social Worker

Recreation Leader

Child Development Specialist

Consultant Psychologist

Consultant Psychiatrist

18. Rank in 1,2,3 etc. order the following '"^J^ **f fj™"*8,^ * play activity center director from the most desired (1) to the least desired (6).

Medical (nursing)

College degree (any major)

Education degree (teacher)

College degree (Social worker)

College degree (Psychology)

College degree (Child Development)

59

19. Rank in 1,2,3 etc. order the following types of experience which you feel are most desirable (1) to least desirable (5) for a play activity center director.

None

Public School

Nursery School

School or clinic for exceptional children

Hospital

20. Place a check (v^ to the left of the three things you consider the most important aspects of a play activity center director's role. Draw a line through any you feel should not be the responsibility of the play activity center director.

Direct volunteer aid (train and schedule).

Transport children from individual rooms.

Attend designated pediatric staff meetings.

Parent education (interpretation of the program).

Record appropriate information on the child's medical record.

Make policies and set regulations for play activity center with the cooperation of the medical staff.

Prepare play materials for the children in isolation.

Supply and supervise a mobile cart.

Select equipment.

Keep daily record of children while in the play activity center.

Supervise lunch for those children able to eat in the play activity center.

Schedule activities for the play activity center.

60

APPENDIX E

Results of Rank Order of

Preferred Training of

Play Activity

Directors

61

Training

Nursing

Any Major

Teacher

Social Worker

Psychology

Child Development

1 x6

2 x5

Rank 3 4

x4 x3 5

x2 6

xl Total

2x6 4x5 2x4 2x3 4x2 5x1 59

0 0 0 1 4 14 25

3 4 3 7 2 0 75

0 0 6 8 5 0 58

16 8 13 0 77

13 5 1 0 0 0 107

Responses From Administrators

N:19

Training 1 x6

2 x5

Rank 3 4

x4 x3 5

x2 6

xl Total

Nursing 0x6 2x5 1x4 2x3 4x2 5x1 29

Any Major 0 0 1 5 I 4 25

Teacher 1 2 3 3 2 0 41

Social Worker 0 3 3 0 2 3 34

Psychology 1 3 2 1 3 1 39

Child Development 9 1 1 0 0 0 63

Responses From Pedia tricians

N; 11

62

Training 1 x6

2 x5

Rank 3 4

x4 x3 5

x2 6

xl Total

Nursing 1x6 2x5 3x4 3x3 3x2 3x1 46

Any Major 0 0 0 1 6 8 23

Teacher 2 1 6 3 3 0 56

Social Worker 0 1 2 8 3 1 44

Psychology 2 7 3 0 1 2 63

Child Development 10 4 1 0 0 0 84

Res ponses From

N-15

Nurses

63

APPENDIX F

Results of Percentage Analysis

of Preferred Training of Play

Activity Directors

64

A: Medical - Nursing

Rank Administrator Pediatrician Nurse N«19 N-ll Nrl5

1 10.5% 0.07. 6.7%

2 21.1% 18.27. 13.37.

3 10.57. 9.17. 20.07.

4 10.57. 18.27. 20.07.

5 21.17. 27.37. 20.0%

6 26.37. 27.37. 20.0%

B: College Degree - Any Major

Rank Administrator Nsl9

Pediatrician N=ll

Nurse N.15

1 P. 07. 0.0% 0.07.

2 0.07» 0.07« 0.07«

3 0.0% 9.1% 0.07.

4 5.3% 45.5% 6.7%

5 21.1% 9.1% 40.07.

6 73.7% 36.4% 53.37.

65

C: Education Degree - Teacher

Rank Administrator Pediatrician Nurse N=19 N.ll N.15

1 15.87. 9.17. 13.37.

2 21.17. 18.27. 6.77.

3 15.87. 27.37. 40.07.

4 36.87. 27.37. 20.07.

5 10.57. 18.27. 20.07.

6 0.07. 0.07. 0.07.

D: College Degree - Social Worker

Rank Administrator N-19

Pediatrician N.ll

Nurse N-15

1 0.07. 0.07. 0.07.

2 0.07. 27.37. 6.7%

3 31.6% 27.37. 13.37.

4 42.1% 0.0* 53.3%

5 26.3% 18.27. 20.0%

6 0.0* 27.37. 6.7%

B: College Degree - Psychology

66

Rank Administrator Pediatrician Nurse Ns19 Ml Nrl5

1 5.3% 9.17. 13.37.

2 31.6% 27.3% 46.7%

3 42.1% 18.2% 20.0%

4 5.3% 9.1% 0.0%

5 15.8% 27.3% 6.7%

6 0.0% 9.1% 13.3%

F: College Degree - Child Development

Rank Adminis trator Pediatrician Nurse N=19 N-ll N-15

1 68.4% 81.87. 66.77.

2 26.37. 9.17. 26.77.

3 5.37. 9.17. 6.77.

4 0.07. 0.07. 0.07.

5 0.07. 0.07. 0.07.

6 0.07. 0.07. 0.07.

APPENDIX G

67

Results of Rank Order of

Preferred Experience of

play Activity Directors

68

Experience 1 x5

2 x4

Rank 3

x3 4

x2 5

xl Total

None 0x5 0x4 0x3 0x2 20x1 20

Public School 1 5 6 8 0 59

Nursery School 7 11 2 0 0 85

School or clini c for exceptional children 6 1 6 7 0 66

Hospital 6 3 6 5 0 70

Responses From Administrators

Na20

Experience 1 x5

2 x4

Rank 3

x3 4

x2 5

xl Total

None 1x5 0x4 0x3 1x2 12x1 19

Public School 2 5 2 5 0 46

Nursery School 5 7 1 1 0 58

School or clini exceptional

c for children 0 2 7 3 2 37

Hospital 6 0 4 4 0 50

Responses From Pediatricians

N.14

69

Rank Experience 1 2 3 4 5 Total

x5 x4 x3 x2 xl

None 0x5 0x4 0x3 0x2 17x1 17

Public School 3 4 3 7 0 54

Nursery School 9 4 3 1 0 72

School or clinic for exceptional children 2 6 4 5 0 56

Hospital 3 3 6 5 0 55

Re sponsc s From Nurses

N-17

APPENDIX H

70

Results of Percentage Analysis

of Preferred Experience of

Play Activity Directors

71

Rank Administrators Pedi atricians Nurses N.20 N=14 N=17

1 0.0% 7.1% 0.0%

2 0.0% 0.0% 0.0%

3 0.0% 0.0% 0.0%

4 0.0% 7.1% 0.0%

5 100.0% 85.7% 100.0%

Rank

1

2

3

4

5

A.Experience - None

Administrators N«20

Pediatricians N=14

5.0%

25.0%

30.0%

40.0%

0.0%

Nurses N.17

14.3% 17.6%

35.7% 23.6%

14.3% 17.6%

35.7% 41.2%

0.0% 0.0%

B. Experience - Public School

72

Rank Adminis trators N-20

Pediatricians N.14

Nurses Ns17

1

2

3

4

5

35.07.

55.07.

10.07.

0.07.

0.07.

35.77.

50.07.

7.17.

7.17.

0.07.

52.97.

23.5%

17.67.

5.97.

0.07.

C. Experience - Nursery School

Rank Administrators N-20

Pediatricians N.14

Nurses Nrl7

1 30.07. 0.07. 11.87.

2 5.07. 14.37. 35.37.

3 30.07. 50.07. 23.57.

4 35.07. 21.47. 29.47.

5 0.07. 14.37. 0.07.

D. Experience - School or clinic for

exceptional children

73

Rank Adminis trators Pediatricians N-20 N=14

30.07. 42.97.

16.7% 0.07.

27.87. 28.67.

22.27. 28.67.

0.07. 0.07.

Nurses N-17

1

2

3

4

5

17.67.

17.6%

35.37.

29.47.

0.07.

E. Experience - Hospital

74

APPENDIX I

Results of Percentage Analysis

of the Most Important Aspects

of the Play Activity

Director's Role

■■■

Admlnis- Pedia- trator trician Nurse Role Aspect of the Play Activity Director N-20 N-16 Nzl8

38.97. 50.07. 33.37.

5.67. 0.07. o.ox

11. IX 6.37. 11. IX

27.87. 12.57. 16.77.

5.67. 0.07. 11.17.

Direct volunteer aid (train and schedule).

Transport children from individual rooms.

Attend designated pediatric staff meetings.

Parent education (interpretation of the program).

Record appropriate information in the child's medical record.

72.27. 87.5X 50.07. Make policies and set regulations for play activity center with the cooperation of the medical staff.

Prepare play materials for the children in isolation.

Supply and supervise a mobile play cart.

Select equipment.

Keep daily record of children while in the play activity center.

5.67. 12.5X 27.87.

11. IX 6.37. 27.87.

11. IX 25.07. 44.47.

5.67. 6.37. 0.07.

5.6X 0.07. 0.07.

00.07. 93.87. 83.37.

Supervise lunch for those children able to eat in the play activity center.

Schedule activities for the play activity center.

76

APPENDIX J

Results of Percentage Analysis of

Those Responsibilities Not a

Part of the Play Activity

Director's Role

J

Adminis- Pedia- trator trician Nurse N-20 N-16 N-18

0.07. 6.37. 0.0%

27.8% 43.8% 44.47.

11.17. 12.57. 22.27.

0.0* 0.07. 5.67.

50.07. 43.87. 33.3%

Role Aspect of the Play Activity Director

Direct volunteer aid (train and schedule).

Transport children from individual rooms.

Attend designated pediatric staff meetings.

Parent education (interpretation of the program).

Record appropriate information in the child's medical record.

0.07. 0.0% 0.07. Make policies and set regulations for play activity center with the cooperation of the medical staff.

Prepare play materials for the children in isolation.

Supply and supervise a mobile play cart.

Select equipment.

Keep daily record of children while in the play activity center.

16.7% 43.8% 22 2Z Supervise lunch for those children able to eat in the play activity center.

0,0% 0.0% 0.07. Schedule activities for the play activity center.

5.6% 0.07. 5.6%

0.0% 6.3% 0.07.

0.07. 0.0% 0.0%

11.17. 18.8% 16.7%